Spinal cord stimulation in pregnancy: a literature review

Spinal cord stimulator malfunction as a result of lead fracture: a case report

Spinal cord stimulation is a successful and thoroughly documented procedure in treating chronic refractory pain. Complications are rare and usually mild, but hardware complications such as electrode dysfunction have been shown to be detrimental in treatment efficacy and patient outcome. We report a case in which a patient diagnosed with complex regional pain syndrome underwent spinal cord stimulation for pain management and experienced lead migration and fracture, resulting in loss of paresthesia and increased pain. This case provides useful clinical information on identifying electrode dysfunction in patients with implanted spinal cord stimulators and emphasizes the importance of preventative measures to reduce the risk of similar complications.

Burst Spinal Cord Stimulation in Pregnancy: First Clinical Experiences

OBJECTIVES

Spinal cord stimulation (SCS) is a treatment for chronic neuropathic pain. It is based on the delivery of electric impulses to the spinal cord, traditionally in a regular square-wave pattern ("tonic" stimulation) and, more recently, in a rhythmic train-of-five "BurstDR" pattern. The safety of active SCS therapy in pregnancy is not established, and recommendations are based on limited casuistic evidence. We present in this study clinical data on a case series of six women treated with burst SCS during pregnancy. In addition, we present the ultrasonographic flow measurements of fetal and uteroplacental blood flow in a pregnant patient.

MATERIALS AND METHODS

Patients were included if they had been implanted with a full SCS system at Aarhus University Hospital, Denmark, between 2006 and 2020 and received active burst SCS stimulation during a pregnancy. Telephone interviews were conducted, including details on SCS therapy, medication, pregnancy course and outcome, and health status of the offspring. In one patient, the uteroplacental and fetal blood flow was assessed in gestational week 29 by Doppler flow measurements performed during both ON and OFF phases of the SCS system.

RESULTS

Six patients were included with a total of 11 pregnancies. Three pregnancies ended in miscarriages, all in the same patient who had preexisting significant risk factors for miscarriage. Eight resulted in a live-born child with normal birth weight for gestational age; seven were born at term, and one was born late preterm, in gestational week 36. Ultrasonographic Doppler flow, measured in one patient, was normal and did not reveal any immediate changes between burst SCS ON and OFF. Seven children were reported healthy with normal neurodevelopment and one physically healthy but with developmental delays.

CONCLUSIONS

The data presented in this study add to the accumulating evidence of the safety of SCS in pregnancy.

Multicentre, clinical trial of burst spinal cord stimulation for neck and upper limb pain NU-BURST: a trial protocol

BACKGROUND

Spinal cord stimulation (SCS) is an established therapy for chronic neuropathic pain and most frequently utilised for Failed Back Surgery Syndrome (FBSS). BurstDR™ also known as DeRidder Burst-SCS, a novel waveform, has demonstrated superiority to conventional tonic stimulation of the thoracic spine in FBSS. There are case reports of an improvement in multidimensional pain outcomes using DeRidder Burst-SCS in the cervical spine for chronic neck and cervical radicular pain. The safety and efficacy of cervical DeRidder Burst-SCS stimulation still however remain undetermined.

METHODS/DESIGN

This is a prospective, multicentre feasibility trial evaluating the safety and therapeutic efficacy of DeRidder Burst-SCS stimulation for the treatment of chronic intractable neck pain with or without radiation to the arm, shoulder, and upper back. After baseline evaluation, subjects will undergo an SCS trial using the Abbott Invisible Trial system according to standard clinical procedures. During the trial phase, SCS leads will be implanted in the cervical epidural space. At the end of the SCS trial, subjects experiencing at least 50% pain relief will be considered for permanent implant. Pain intensity, medication usage, and other multidimensional pain outcomes will be collected. The timing of these will be at baseline, end of the SCS trial and at 3-, 6-, and 12-month visits. Incidence of adverse events will be collected throughout the study duration.

DISCUSSION

The results of this feasibility study will validate the efficacy and safety of DeRidder Burst-SCS stimulation in the cervical spine. The results obtained in this study will potentially be used to generate a level 1 evidence-based study with formal statistical hypotheses testing.

TRIAL REGISTRATION

www.clinicaltrials.gov Identifier: NCT03159169.

"Please mind the gap": successful use of ultrasound-assisted spinal anesthesia for urgent cesarean section in a patient with implanted spinal cord stimulation system for giant chest wall arteriovenous malformation - a case report

Background

The use of Spinal Cord Stimulation (SCS) system to treat medically refractory neuropathic pain is increasing. Severe neuropathic pain can be found in giant chest wall arteriovenous malformations (AVMs), exceedingly rare and debilitating abnormalities, rarely reported during pregnancy.

Case presentation

We present a report of a pregnant patient with implanted Spinal Cord Stimulation (SCS) system because of painful thoracic AVM scheduled for an urgent cesarean section in which we used lumbar ultrasound (US) to rule out the possibility to damage SCS electrodes and to find a safe site to perform spinal anesthesia.

Conclusions

The use of lumbar US to find a safe site for a lumbar puncture in presence of SCS system in a patient affected by painful thoracic AVM makes this case a particularly unique operative challenge and offers a new possible use of ultrasound to detect a safe space in patients with SCS implant.

Complex Regional Pain Syndrome Management: An Evaluation of the Risks and Benefits of Spinal Cord Stimulator Use in Pregnancy

OBJECTIVE

We present a case of a young woman diagnosed with complex regional pain syndrome (CRPS) who underwent spinal cord stimulator (SCS) implantation. She had 2 successful pregnancies following implantation.

DESIGN

We evaluated the electronic medical records of the patient following SCS implantation and while pregnant with her second and third children. A phone interview was conducted after her third pregnancy to discuss her experience with SCS use during and after pregnancy.

SETTING

Physical medicine and rehabilitation pain management clinic and obstetrician clinic, affiliated with the Medical College of Wisconsin in Milwaukee, Wisconsin.

SUBJECT

A 26-year-old woman with history of CRPS type I.

RESULTS

This 26-year-old woman was diagnosed with CRPS type I after left knee surgery. All conservative treatments had failed prior to her undergoing SCS implantation after the birth of her first child. SCS implantation brought near complete resolution of her symptoms. When she became pregnant with her second child, she turned off her SCS. Her CRPS symptoms intensified, but she had a normal pregnancy. She turned the SCS back on postpartum and elected to continue its use throughout her third pregnancy. She had a normal pregnancy, and her CRPS symptoms were well controlled. The patient and her children are currently healthy. Her SCS remains functional and effective.

CONCLUSION

Both an SCS and many medications used for pain management in CRPS could cause harm to both mother and fetus in pregnancy. Further research must be done to determine the safety and efficacy of SCS use in pregnancy.

Spinal Cord Stimulation in Pregnant Patients: Current Perspectives of Indications, Complications, and Results in Pain Control: A Systematic Review

Spinal cord stimulation (SCS) has been described as a valuable neuromodulator procedure in the management of chronic medically untreated neuropathic pain. Although the use of this technique has been published in many papers, a question still remains regarding its applicability in pregnant patients. The goal of this paper is to discuss the risks, complications, and results as well as the prognosis of SCS in pregnant patients. We performed a systematic review from 1967 to 2018 using the databases MEDLINE, LILACS, SciELO, PubMed, and BIREME, utilizing language as selection criteria. Eighteen studies that met our criteria were found and tabulated. SCS is a reversible and adjustable surgical procedure, which results in patients that demonstrated a significant effect in the reduction of pain intensity in pregnant patients. The etiologies most frequent were complex regional pain and failed back pain syndromes, which together represented 94% of analyzed cases. The technical complications most frequent were lead migration (3%, n = 1). Regarding the risks, the authors did not show significative factors among the categorical variables that can suggest a teratogenicity, while the maternal risks have been associated to the consequences of technical complications due to, among other factors, improvement of abdominal pressure during pregnancy and delivery. Finally, although there are not significative cohorts of pregnant patients, the procedure is still an effective surgical approach of neuropathic pain associated to lower rates of complications and significative improvement in the quality of life of patients during pregnancy.

Chronic pain during pregnancy: a review of the literature

BACKGROUND AND PURPOSE

The majority of the reviews and studies on chronic pain in pregnancy have primarily focused on the pharmacological and non-pharmacological treatment options. The purpose of our review was to identify evidence-based clinical research for the evaluation and management of preexisting chronic pain in pregnancy, chronic pain associated with pregnancy, and chronic pain in relation to mode of delivery.

METHODS

A literature search was undertaken using the search engines PubMed, CINAHL, EBSCOhost, and Web of Science. Search terms used included "chronic pain" AND "pregnant OR pregnancy" OR "pregnancy complications" from inception through August 2016.

RESULTS

The basis of this review was the 144 articles that met inclusion criteria for this review. Based on our review of the current literature, we recommend 7 guidelines for chronic pain management during and after pregnancy: 1) complete history and physical examination; 2) monitor patients for alcohol, nicotine, and substance use; 3) collaborate with patient to set treatment goals; 4) develop a management plan; 5) for opioids, use lowest effective dose; 6) formulate a pain management plan for labor and delivery; and 7) discuss reproductive health with women with chronic pain.

CONCLUSION

The management of chronic pain associated with pregnancy is understudied. Obstetrical providers primarily manage chronic pain during pregnancy. Some general guidelines are provided for those health care providers until more information is available.

Is spinal cord stimulation safe? A review of 13 years of implantations and complications

OBJECTIVE

The aim of this review was to evaluate the complications of spinal cord stimulation (SCS) for chronic pain.

METHODS

This was a retrospective case series of 212 patients treated with SCS for chronic lower-limb neuropathic pain between March 2002 and February 2015 in a Reims academic hospital. All patients received a surgically implanted paddle-type electrode. Complications with this technique are here described and analyzed, and other treatment and preventative methods proposed.

RESULTS

The major indication was 'failed back surgery syndrome', and 74 (35%) patients experienced complications, of which 57% were benign, while 42% required invasive treatment. Most frequent complications (n=22, 10%) were hardware malfunctions. There were two cases (0.9%) of postoperative neurological deficit and nine (4.2%) with postoperative infections. All patients received the appropriate treatment for their complication.

CONCLUSION

Despite the presence of complications, SCS is still a safe technique, although careful patient selection and proper surgical technique can help to avoid major complications.

Pregnancy in a Series of Dystonia Patients Treated with Deep Brain Stimulation: Outcomes and Management Recommendations

BACKGROUND

Medically refractory dystonia affects children and young adults, and deep brain stimulation (DBS) can allow some patients to regain functional independence. Women with dystonia treated with DBS may wish to conceive a child, but there is limited published information on pregnancy and DBS.

OBJECTIVE

To describe a series of dystonia patients treated with DBS who later became pregnant and provide guidelines for women treated with DBS considering conception.

METHODS

We reviewed all dystonia DBS cases implanted at the University of California, San Francisco, and University of Alabama at Birmingham from 1998 to 2015 and identified patients who became pregnant. Patient records were reviewed and structured interviews were conducted.

RESULTS

Six dystonia patients were identified [1 currently pregnant and 7 live births (including 1 twin pair)]. Patients (n = 5) with pre- and postoperative BFMDRS (Burke-Fahn-Marsden Dystonia Rating Scale) scores improved by 65.9% after DBS. All pregnancies and deliveries were uncomplicated (the delivery mode was not influenced by the presence of DBS), except for 1 child, who was born premature at 35 weeks' gestation. Stimulation remained on (n = 3) or off (n = 4) during deliveries. DBS neurostimulators did not hinder breastfeeding.

CONCLUSIONS

In this small sample, pregnancy, delivery, and breastfeeding were safe in dystonia patients treated with DBS. The presence of DBS should not be a contraindication to pregnancy.